Morphology and mucosal biochemistry of gastroschisis intestine in urine-free amniotic fluid

miRNA-143 expression is associated with inflammation and time of exposure to amniotic fluid in experimental gastroschisis

OBJECTIVE

Gastroschisis (GS) is a congenital anomaly in the abdominal wall with the intestinal loops exiting laterally to the umbilicus. The contact of the loops with Amniotic Fluid (AF) causes an inflammatory process in the exposed part, leading to an extended hospital stay and an increased risk of morbidity due to alterations related to intestinal motility. The authors aimed to evaluate the time of exposure to the AF in the experimental GS and to search for potential biomarkers of intestinal inflammation by measuring microRNAs.

METHODS

Rat fetuses were divided into three groups: a) CONTROL, b) GS reared on day 18 (GS = 18), and c) GS reared on day 19.5 (GS = 19) (term = 22 days). On day 21.5, the fetuses were removed for biometric parameters and biochemical analyses: 1) Biometrics: Body and Intestinal Weight (BW, IW), and intestinal-body weight ratio (IW/BW); 2) Descriptive histopathology and 3) miR-143 quantification by real-time Polymerase Chain Reaction (PCR).

RESULTS

BW was higher in CONTROL than GS 18 and G19 (p < 0.05). IW, IW/BW, intestinal water, and mRNA-143 were higher in GS 18 and GS 19 than in CONTROL, and GS 18 was higher than GS 19 (p < 0.05). The average of the inflammation score from the intestinal wall with mucosal inflammation and intra-epithelial lymphocytes shows worst in GS 18 and GS 19 vs. CONTROL (p < 0.05).

CONCLUSIONS

The tissue expression of mRNA-143 and the morphological changes in the intestine of GS worsened according to the time of exposure to AF, which could be a possible marker of fetal intestinal damage.

Elective delivery at 34 weeks vs routine obstetric care in fetal gastroschisis: randomized controlled trial

OBJECTIVE

To evaluate whether elective preterm delivery (ED) at 34 weeks is of postnatal benefit to infants with isolated gastroschisis compared with routine obstetric care (RC).

METHODS

Between May 2013 and September 2015, all women with a sonographic diagnosis of fetal gastroschisis referred to a single tertiary center, before 34 weeks' gestation, were invited to participate in this study. Eligible patients were randomized to ED (induction of labor at 34 weeks) or RC (spontaneous labor or delivery by 37-38 weeks, based on standard obstetric indications). The primary outcome measure was length of time on total parenteral nutrition (TPN). Secondary outcomes were time to closure of gastroschisis and length of stay in hospital. Outcome variables were compared using appropriate statistical methods. Analysis was based on intention-to-treat.

RESULTS

Twenty-five women were assessed for eligibility, of whom 21 (84%; 95% CI, 63.9-95.5%) agreed to participate in the study; of these, 10 were randomized to ED and 11 to RC. The trial was stopped at the first planned interim analysis due to patient safety concerns and for futility; thus, only 21 of the expected 86 patients (24.4%; 95% CI, 15.8-34.9%) were enrolled. Median gestational age at delivery was 34.3 (range, 34-36) weeks in the ED group and 36.7 (range, 27-38) weeks in the RC group. One patient in the ED group delivered at 36 weeks following unsuccessful induction at 34 weeks. Neonates of women who underwent ED, compared to those in the RC group, showed no difference in the median number of days on TPN (54 (range, 17-248) vs 21 (range, 9-465) days; P = 0.08), number of days to closure of gastroschisis (7 (range, 0-15) vs 5 (range, 0-8) days; P = 0.28) and length of stay in hospital (70.5 (range, 22-137) vs 31 (range, 19-186) days; P = 0.15). However, neonates in the ED group were significantly more likely to experience late-onset sepsis compared with those in the RC group (40% (95% CI, 12.2-73.8%) vs 0%; P = 0.03).

CONCLUSION

This study demonstrates no benefit of ED of fetuses with gastroschisis when postnatal gastroschisis management is similar to that used in routine care. Rather, the data suggest that ED is detrimental to infants with gastroschisis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Outcomes of gastroschisis early delivery: A systematic review and meta-analysis

BACKGROUND/PURPOSE

Elective preterm delivery (EPD) of a fetus with gastroschisis may prevent demise and ameliorate intestinal injury. While the literature on optimal timing of delivery varies, we hypothesize that a potential benefit may be found with EPD.

METHODS

A meta-analysis of publications describing timing of delivery in gastroschisis from 1/1990 to 8/2016 was performed, including studies where either elective preterm delivery (group 1, G1) or preterm gestational age (GA) (group 2, G2) were evaluated against respective comparators. The following outcomes were analyzed: total parenteral nutrition (TPN), first enteral feeding (FF), length of stay, ventilator days, fetal demise, complex gastroschisis, sepsis, and death.

RESULTS

Eighteen studies describing 1430 gastroschisis patients were identified. G1 studies found less sepsis (p<0.01), fewer days to FF (p=0.03), and 11days less of TPN (p=0.07) in the preterm cohort. Comparatively, G2 studies showed less days to FF in term GA (p=0.02).Whereas G1 BWs were similar, G2 preterm had a significantly lower BW compared to controls (p=0.001).

CONCLUSIONS

Elective preterm delivery appears favorable with respect to feeding and sepsis. However, benefits are lost when age is used as a surrogate of EPD. A randomized, prospective, multi-institutional trial is necessary to delineate whether EPD is advantageous to neonates with gastroschisis.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Treatment of bowel in experimental gastroschisis with a nitric oxide donor

OBJECTIVE

To reduce the harmful effect of bowel exposure to amniotic fluid in gastroschisis, we used the nitric oxide (NO) donor S-nitrosoglutathione (GSNO) in an animal model of gastroschisis and assessed the ideal concentration for treatment of changes in bowel.

STUDY DESIGN

Gastroschisis was surgically induced in rat fetuses on day 18.5 of gestation. The fetuses were divided into 5 groups (n = 12 animals/group): control (C), gastroschisis (G), gastroschisis + GSNO 5 μmol/L (GNO1), gastroschisis + GSNO 0.5 μmol/L (GNO2), and gastroschisis + GSNO 0.05 μmol/L (GNO3). On day 21.5 of gestation, fetuses were collected by cesarean delivery. Body and intestinal weight were measured and the bowels were either fixed for histometric and immunohistochemical study or frozen for Western blotting. We analyzed bowel morphometry on histological sections and expression of the NO synthase (NOS) enzymes by Western blotting and immunohistochemistry. Data were analyzed by analysis of variance or Kruskal-Wallis test when appropriate.

RESULTS

Morphological and histometric measurements of weight, diameter, and thickness of the layers of the intestinal wall decreased with GSNO treatment, especially in the GNO3 group, when compared with the G group (P < .05). The expression of neuronal NOS, endothelial NOS, and inducible NOS decreased mainly in GNO3 group compared to the G group (P < .05), with no difference compared to C group (P > .05).

CONCLUSION

Fetal treatment with 0.05 μmol/L GSNO resulted in significant improvement of bowel morphology in gastroschisis.

Erythropoietin restores bowel damage and hypoperistalsis in gastroschisis

BACKGROUND AND PURPOSE

Despite the decreased mortality in gastroschisis (Gx), patients experience postoperative intestinal hypoperistalsis, malabsorption, and shortened bowel length. The trophic effects of recombinant human erythropoietin (rEpo) in the developing small bowel have been reported, increasing the length and height of the villi, and villous surface area. This study investigated the effects of rEpo on intestinal malfunction in the chick embryos with Gx.

METHODS

Thirteen-day-old fertilized chicken eggs were used to create Gx model. Study groups included the following: group 1, control; group 2, Gx-only; group 3, Gx + 0.075% saline exchange; group 4, Gx + 10 IU rEpo exchange; group 5, Gx + 20 IU rEpo exchange. The bowels were evaluated by in vitro muscle strip technique, and the response was expressed as a percentage of the maximum carbachol-evoked contraction (Emax). In addition, parasympathetic ganglion cells per 10 plexuses and villi height were determined by light microscopy. Results were evaluated statistically by Mann-Whitney U, chi2, and Fisher's Exact test tests.

RESULTS

Saline exchange had no effect on ganglion cell number (P = .63) and villi height (P = .10). In group 4, ganglion cell number was not increased (P = .82), but villi height increase was significant (P = .03). In Gx + 20 IU rEpo group, both the number of ganglia (P = .0001) and villi height (P = .002) were significantly increased. The decrease in contractility in group 2 (P = .0121) was significantly reversed by rEpo 20 IU treatment (P = .0216), no significant difference was obtained in groups 3 (P = .0809) and 4 (P = .1516) compared with group 2.

CONCLUSION

These data suggest that rEpo has prokinetic effects on hypoperistalsis and restores bowel damage in Gx.

A randomized controlled trial of elective preterm delivery of fetuses with gastroschisis

BACKGROUND

Elective preterm delivery of the fetus with gastroschisis may help to limit injury to the extruded fetal gut and thus promote faster recovery of neonatal gut function and earlier hospital discharge. This hypothesis has not previously been tested in a prospective randomized controlled trial.

METHODS

Between May 1995 and September 1999, all women referred to a single tertiary center before 34 weeks' gestation with a sonographically diagnosed fetal gastroschisis were invited to participate in a randomized controlled trial. Eligible patients were randomized to elective delivery at 36 weeks or to await the onset of spontaneous labor. The method of delivery was not prescribed by the trial. Primary outcome measures in the neonate were the time taken to tolerate full enteral feeding (150 mL/kg per day) and duration of hospital stay.

RESULTS

Of 44 eligible women, 42 were randomized, 21 to elective delivery and 21 to await spontaneous labor. There were 20 liveborn infants in each group. Four babies in the elective group and 4 in the spontaneous group delivered before 36 weeks' gestation but were included in the analysis on an intention-to-treat basis. Mean gestational age at delivery was 35.8 weeks in the elective group and 36.7 weeks in the spontaneous group. Primary closure of the gastroschisis was achieved in a similar proportion (80%-85%) of infants in both groups. Two babies in the elective group died from short gut complications. In the survivors, there was a trend in favor of a shorter median time to achieve full enteral feeding (30.5 vs 37.5 days) and a shorter median duration of hospital stay (47.5 vs 53 days) in the elective group, but this was not statistically significant. These findings remained unaltered when the data were reanalyzed after (a) excluding infants with intestinal atresia or (b) excluding infants born before 36 weeks' gestation.

CONCLUSIONS

Although limited by the small number of patients, this randomized controlled trial demonstrates no significant benefit from elective preterm delivery of fetuses with gastroschisis.